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Tension and Cervicogenic Headaches:

Tension and Cervicogenic Headaches:

The staggering variety of headaches-the International Headache Society has identified 13 broad categories and 128 distinct disorders1-and the interpatient variability can make diagnosis difficult. Fortunately, most headaches can be identified and treated effectively if you know what to look for. The history and the pattern of pain often point to the correct diagnosis.

In this article, we focus on 2 of the most common types that physicians encounter: tension-type headache-both episodic and chronic-and cervicogenic headache. We examine the diagnostic features of each, as well as characteristics that may cause confusion with other types of headache, such as migraine and chronic daily headache. We then provide management guidelines.

Episodic versus chronic types. Tension-type headache (or simply tension headache) is the most common type of primary headache and is widely prevalent in the general population. It ranges from mild to fairly disabling, with significant socioeconomic impact.

Tension headache has been subclassified into 2 main categories: episodic tension-type headache (ETTH) and chronic tension-type headache (CTTH). Rasmussen and colleagues2 reported a lifetime prevalence of tension headache of 69% in men and 88% in women. ETTH appears to be more common than CTTH; in a recent review, the overall prevalence in a 1-year period was 38.3% for ETTH and 2.2% for CTTH.3 For either type of tension headache, a thorough history and physical examination can establish the diagnosis and further evaluation is generally unnecessary.

Diagnostic features. There is a tremendous degree of interpatient variability in the natural course that tension headache-either episodic or chronic-may take. Presenting features pertain equally to both types of headache. The difference is primarily in the frequency of headaches and the presence of associated symptoms. In addition, patients with CTTH may have a positive family history.

In both ETTH and CTTH, the pain is usually bilateral and typically described as dull, bandlike, aching, pressing, or tightening in the frontal, temporal, or occipital regions. It may be associated with neck symptoms. The intensity of tension headache may range from mild to severe and varies throughout the day. Tension headache is sometimes difficult to differentiate from migraine: both types of headaches may be associated with a throbbing pain, unilateral location, accompanying neck pain and muscle spasm, and sleep disturbance, as well as a positive family history.

As with migraine, CTTH—often a disabling syndrome—may be associated with nausea (although without emesis) or with phonophobia or photophobia. ETTH does not involve these symptoms. Episodes of tension headache-both chronic and episodic types-may last anywhere from 30 minutes to 7 days, but the frequency of CTTH episodes is much greater. Diagnostic criteria for ETTH and CTTH are listed in Table 1. Chronic daily headache is not the same as CTTH and should not be confused with it (Box).

Although tension headaches—as the name suggests–are frequently triggered or aggravated by stress, they can also stem from poor nutrition, fatigue, insufficient sleep, temporomandibular joint dysfunction, alcohol use, hormonal fluctuations, and weather changes. A detailed patient history is essential for noting these or any other factors that may be contributing to the problem.

With the psychological or stress component of tension headaches, it is difficult to establish cause and effect. Psychological comorbidities, such as anxiety and depression, may contribute to tension headaches, or they may themselves be caused or aggravated by the unrelenting pain. In some patients, other psychiatric conditions may coexist without any causal relationship to tension headaches.

It is important to rule out potentially dangerous causes of headache, such as brain tumor, meningitis, hemorrhage, and stroke. The following signs or symptoms suggest the need for further workup4:

  • Onset of new headache or report that the headache is the worst ever experienced.
  • Change in intensity, frequency, or characteristics of the headache.
  • Headache associated with neurologic findings on examination, such as stiff neck, papilledema, mental status changes, persistent neurologic deficits, seizure, or electroencephalographic evidence of a lesion.

  • New onset of daily headache, or progressively increasing headaches.
  • New onset of headaches with exertion.


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